CONTRATA CON NOSOTROS – AR INSURANCE GROUP INC

First Name *

Last Name *

Date of Birth *

Gender *MaleFemale

Email *

National Producer Number *

Resident Insurance Lic.#&State *

Social Security Number *

cell *

Address *

Apt/suite

City

State

Zip Code

País

1. Have you ever been charged, convicted, plead guilty, or no contest to any Felony or Misdemeanor? *YesNo

2. Have you ever been or are you currently being investigated have any pending indictments, lawsuits, or have you ever been in a lawsuit with an insurance company? *YesNo

3. Have you ever had an appointment with any insurance company terminated for cause or been denied an appointment? *YesNo

4. Has any lawsuit or claim ever been made against you by a surety company, or errors and omissions insurer arising out of your sales or practices, or, have you been refused sure bonding or E&O coverage? *YesNo

5. Have you ever had an insurance or securities license denied, suspended, canceled, or revoked? *YesNo

6. Have you personally filed a bankruptcy petition or declared bankruptcy? *YesNo

6A. If you answered YES to the previous question. Is the bankruptcy pending? *YesNo

7. Have you ever had any judgments, garnishments, or liens against you? *YesNo

8. How many ACA Open Enrollments have you participated in? *

Life, Accident, Health and HMO License *

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Property and Casualty License

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CMS FFM Certificate

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Errors and Omissions E&O

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Signature *

Date *

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